Scott Nabity, MD, MPH
Resident in Medicine-Pediatrics at MGH
Pediatric Hospital Care in Uganda
PGY 4
January
24, 2017
This trip makes the third month-long tours at the teaching
hospital of the Mbarara University of Science and Technology (MUST), including
one adult and two pediatric ward rotations. A recurring theme of respect that I
reflect upon with each visit is the resiliency of the patients, their families,
and the hospital staff in the persistent effort to get sick patients, particularly
the children, well again.
“Rosy” is one such patient. She is approximately 12 years
old and, like too many adolescents in Africa, suffers the effects of rheumatic
heart disease. Her disease is severe and local doctors are working to arrange a
valve repair internationally. I first met Rosy exactly one year ago when she
was previously admitted for decompensated heart failure. It was a surprise to
see her again this year, her planned surgery delayed by complications of
coordinating a transnational care plan. In the crowded space of the pediatric
ward, I found Rosy again in decompensated failure. She lay even more wasted,
unable to sit upright, working to breathe with taut ascites. She and her family
spent day after day waiting for the diuretics to take effect. We gave her oxygen
but mostly she found respite by assuming a prone position with her knees tucked
tightly beneath her and her forehead pressed into her palms resting on the bed.
This was the position I typically found Rosy morning after morning, with
parents and little brother at the bedside, until she slowly experienced some
improvement. Her parents never complained, and neither did Rosy. Their only immediate
request was to have a photo of Rosy to share her progress with villagers, the feasibility
of any surgical intervention uncertain.
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Families preparing meals and washing clothes on
the hospital grounds, which also serve as sleeping spaces. Caregivers are
responsible for providing food, bedding, and many medications/medical supplies
for patients.
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While the stamina patients like Rosy exhibit is incredible,
perhaps I can more realistically appreciate the resiliency of the resident
doctors. For those of us fortunate enough to train in the bounty of a Boston hospital,
facing the quotidian diagnostic and therapeutic limitations of the Ugandan
public hospital can be paralyzing. Much of our training simply doesn’t
translate, particularly when diagnostics are not available. Further, the volume
and acuity of pediatric patients at home pales in comparison to that in the
Ugandan context. In fact, a substantial proportion of the daily admissions
would be triaged to an intensive care unit in the US, an extremely thin
resource in Uganda. Many of the severely ill children we could easily support
to wellness in the US just do not survive at this hospital. Childhood death,
while never unremarkable, is not a rare event.
This reality is seated in stark contrast to my pediatric
exposure back home. The frequency of child deaths I’ve experienced at my
hospital over nearly 4 years of training was generously exceeded by fatalities
in a 4-week period in Mbarara. When children die, the volume dictates that residents
move on to the next sick patient, which seemingly takes its toll. Deaths are
reviewed and prevention strategies are discussed. However there are no vigils,
no special forums, and there are no psychosocial rounds. The work simply
continues. And I presume at the end of the day, the doctors in training hug
their own children extra tightly.
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Pediatric residents
and medical students providing post resuscitation care to a child who developed
hypoxemic cardiac arrest during morning rounds. The boy eventually died.
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My training programs have implemented a number of measures
to retain humanity and resilience in medicine, going so far as to periodically
insert group meditation sessions in place of the traditional learning
conference. Physician trainee burnout in the US is a serious and growing
concern, and our leadership is attempting innovative means to combat it.
Indeed, our training is rigorous but our experience with dying children is
unequal. I admire the work of our Ugandan colleagues. And with each visit I
appreciate more the relative luxury we have in keeping most children
healthy in Boston, as well as the system of buffers in place to keep each other
going when things fall apart.
